Healthcare Provider Details

I. General information

NPI: 1134526429
Provider Name (Legal Business Name): NORTH SHORE EAR, NOSE & THROAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 ENDICOTT ST SUIRE 100
DANVERS MA
01923-3623
US

IV. Provider business mailing address

104 ENDICOTT ST SUIRE 100
DANVERS MA
01923-3623
US

V. Phone/Fax

Practice location:
  • Phone: 978-745-6601
  • Fax:
Mailing address:
  • Phone: 978-745-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number229239
License Number StateMA

VIII. Authorized Official

Name: DR. RICHARD MUGGE
Title or Position: TREASURER
Credential: M.D.
Phone: 978-745-6601